Neuro Sensory Final

The registered nurse is teaching a coworker about the care to be taken in clients with neurologic changes associated with aging. Which statement made by the coworker indicates the nurse needs to intervene?

"Clients with decreased sensory perception of touch should be carefully monitored for infection."

A client who has open-angle (chronic) glaucoma is scheduled for eye surgery to promote aqueous humor outflow. The nurse evaluates that the client understands the preoperative teaching about the first 24 hours after surgery when the client makes which statement?

"I should avoid coughing."

A client with multiple sclerosis is informed that it is a chronic progressive neurologic condition. The client asks the nurse, "Will I experience pain?" What is the nurse's best response?

"Pain is not a characteristic symptom of this condition."

The nurse is performing a neurologic assessment on a client and is completing the Glasgow Coma Scale (GCS). What components make up this assessment tool? Select all that apply.

-Best verbal response -Best motor response -Best eye-opening response

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult what expected sensory losses associated with aging will the nurse expect to find? Select all that apply.

-Diminished sensation of pain -Impaired hearing of high-frequency sounds

Which cranial nerves assist with both sensory and motor functioning in a client? Select all that apply

-Facial -Trigeminal

A hospitalized client is receiving pyridostigmine for control of myasthenia gravis. In the middle of the night, the nurse finds the client weak and barely able to move. Which additional clinical findings support the conclusion that these responses are related to pyridostigmine? Select all that apply.

-Respiratory depression -Decreased blood pressure -High-pitched gurgling bowel sounds

A client has rotator cuff surgery. What should be included when the nurse performs a neurovascular assessment of the affected extremity immediately after surgery? Select all that apply

-Skin color -Movement of the hand -Sensations in the extremity

A client arrives at the nursing unit with neurological deficits after a motor vehicle accident. Using the Glasgow Coma Scale, the nurse assesses what client responses? Select all that apply.

-Verbal response to speech -Eye opening in response to speech -Motor activity in response to a verbal command

What is the score in the Glasgow Coma Scale when the client has no eye response after a head injury?

1

What is the maximum amount of time the nurse should allow an older adult with a cerebrovascular accident (also known as "brain attack") to remain in one position?

1 to 2 hours

A client is admitted to the emergency department with head trauma resulting from an accident. The nurse uses the Glasgow Coma Scale to determine the patient's neurologic function. The patient opens the eyes to painful stimuli, is able to speak but uses inappropriate words,and flexes away from pain. Which number should the nurse use to document the patient's neurological function?

9

While assessing a client's vision, the nurse finds that the client is unable to read line 20 of the eye chart when made to stand at a distance of 20 feet. Which ophthalmic condition can be anticipated in this client?

Abnormal distant vision

A 50-year-old male client has difficulty communicating because of expressive aphasia after a brain attack (CVA). When the nurse asks the client how he is feeling, his wife answers for him. How should the nurse address this behavior?

Acknowledge the wife but look at the client for a response.

A client is taking phenytoin to treat clonic-tonic seizures. The client's phenytoin level is 16 mg/L. Which action should the nurse take?

Administer the next dose of the medication as prescribed

After cataract surgery, a client reports feeling nauseated. How can the nurse help relieve the nausea?

Administer the prescribed antiemetic drug.

The nurse is planning care for several clients. Which client is at the highest risk for glaucoma?

African American

A client's relative asks the nurse what a cataract is. What explanation should the nurse provide?

An opacity of the lens

Three days after admission to the hospital for a brain attack (cerebrovascular accident; CVA), a client has a nasogastric tube inserted and is receiving continuous tube feedings. Which action should the nurse take to best evaluate whether the feeding is being absorbed?

Aspirate for a residual volume

A client returns from the post-anesthesia care unit after a right rotator cuff repair. What should the nurse do when performing a neurovascular assessment?

Assess for capillary refill in the nail

A client who has been experiencing double vision, drooping of the eyelids, and fatigue visits the neurologic clinic. A diagnosis of myasthenia gravis is made, and the healthcare provider prescribes pyridostigmine. The nurse should teach the client that it is important to take this drug based on what schedule?

At the exact time intervals prescribed

A client is admitted to the hospital for surgery for an extracapsular cataract extraction with an intraocular lens implantation. What is most important to include in the teaching program regarding postoperative activities?

Avoid bending from the waist

A client experiences a traumatic brain injury. Which finding identified by the nurse indicates damage to the upper motor neurons?

Babinski response

A client who just has been diagnosed with primary open-angle glaucoma (POAG) refuses therapy. The nurse reinforces that it is important for the client to seek treatment because if POAG is left untreated it may lead to what?

Blindness

A nurse is caring for a newly admitted client in a long-term care facility. The nurse notes that the client has a decreased attention span and cannot concentrate. The nurse suspects which effects of sensory deprivation?

Cognitive response

What should the nurse do to assess the neurovascular status of an extremity casted from the ankle to the thigh?

Compress and release the toenails of the affected foot.

Which desired effect of therapy should the nurse explain to the client who has primary angle-closure glaucoma?

Controlling intraocular pressure

A client with myasthenia gravis is to receive immunosuppressive therapy. What assures the nurse that this therapy will be effective?

Decreases the production of autoantibodies that attack acetylcholine receptors

A client visits a neurologist after experiencing a tonic-clonic seizure. The neurologist suspects a brain tumor, and a computed tomography (CT) scan is scheduled. Before the test what should the nurse do?

Describe the equipment involved

A nurse observes dorsiflexion of the big toe and fanning of other toes when the lateral side of a client's foot is stroked with an applicator stick during a neurological examination. What should the nurse document in the client's medical record?

Exhibits a positive Babinski sign

The nurse is planning care for several clients. Which client is at the highest risk for diabetic retinopathy?

Hispanic

After cataract surgery the nurse teaches a client how to self-administer eye drops. The nurse reinforces the use of what technique?

Holding the dropper tip above the conjunctival sac

Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma?

Impairment of peripheral vision

When completing a neurological assessment, the nurse determines that a client has a positive Romberg test. Which finding supports the nurse's conclusion?

Inability to stand with feet together when eyes are closed

The nurse considers that sensory restriction in a client who is blind can do what?

Increase the use of daydreaming and fantasy

During the neurological assessment of a client with a tentative diagnosis of Guillain-Barre syndrome, what does the nurse expect that the client will manifest?

Increased muscular weakness

A client who is legally blind is admitted to the hospital for surgery. What nursing action is most appropriate when caring for this client?

Keep the furniture in the same location in the room

A client who had a recent brain attack (CVA) has not had a bowel movement for five days. After addressing this problem, what does the nurse anticipate will be prescribed daily to prevent this from occurring in the future?

Mild stool softener to make stool easier to pass

A client with a history of seizures is admitted with a partial occlusion of the left common carotid artery. The client has been taking phenytoin for 10 years. When planning care for this client, what should the nurse do first?

Obtain a history of seizure type and incidence

After a cerebrovascular accident (also known as brain attack) a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. What lobe of the brain should the nurse conclude is likely affected?

Parietal

A nurse is caring for a client who had a brain attack (cerebrovascular accident) two weeks ago. What should the nurse do to help the client develop independence?

Reinforce success in tasks accomplished.

A neuromuscular blocking agent is administered to a client before electroconvulsive therapy. At this time, what should the nurse monitor the client for?

Respiratory difficulties

A client is admitted with a brain attack (CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. What should the client's plan of care include?

Teaching the client to use head movements to scan the left field of vision

The spouse of a client who had a brain attack (cerebrovascular accident) tells the home health nurse that the client cries easily and without provocation. The spouse asks why the client is so emotionally fragile. What is the nurse's best response?

This behavior is a common response over which the client has very little control

Which health problem does the nurse identify from an older client's history that increases the client's risk factors for a cerebrovascular accident (CVA, also known as "brain attack")?

Transient ischemic attacks (TIAs)

A client is admitted to the hospital after having a tonic-clonic seizure. The client has a two-year history of a seizure disorder, but the seizures have been well controlled by phenytoin for the last six months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which is the best response by the nurse?

You are worried about having more seizures?